Getting in on femto-phaco

This article originally appeared in Ophthalmology Management, Volume: 18, Issue: September 2014, pages 44-46, 67 and can be found on the Ophthalmology Management website here. Sighpath Medical surgeons Dr. Patterson & Dr. Kohler are quoted.

Getting in on femto-phaco

Purchasing the laser is not your only option.


While femto-phaco surgery continues to be a headline-generator at ophthalmology meetings, the investment required may discourage adoption among smaller practices concerned they don’t have sufficient patient volume. Some fans, though, have found other ways to offer the innovation to their patients with a business model that does not involve the purchase of a laser. Read on for two creative solutions devised by surgeons who wanted to get in on cataract surgery’s latest innovation. (Also, see the sidebar, “Don’t Write Off Purchasing,” on page 46.)


Beyond the price tag

Femtosecond laser suites entail costs beyond the initial purchase price, says Larry Patterson, MD, Crossville, Tenn. Consider these expenses:

• Maintenance. Dr. Patterson notes that practices pay ongoing maintenance costs, as well as the key card.

• Insurance. “You’ll have to buy a lot more of it if you have this laser in your office,” Dr. Patterson says.

• Staff. You will need someone with special training to operate laser. And what will that staff member do on your non-surgery days?

Considering efficiency and patient volume

In addition to the cost of the laser suite, practices report that the extra step of treatment with the femtosecond laser takes time, which means fewer procedures over a given period. Also, the practice will have to perform a minimum number of femto-phaco procedures to meet the monthly payments for the system, leading to concerns over adequate patient volume for conversion.

According to a spokesperson at Alcon, a practice is likely to break even with 20 femto procedures a month, or 240 per year, and should hit a positive ROI with about 30 procedures a month (360 per year). This depends, however, on patient fees and the number of patient-pay procedures, such as premium IOLs, the practice achieves. For practices that can make these volumes, owning a femto laser system may be a profitable move — much depends on patient base.

“When I hear surgeons talk about 60%, 70%, 80% conversion rates, I think, ‘Wow!’ And if you practice in a wealthy area, that’s one thing,” says Dr. Patterson. Otherwise, practices may find it challenging to achieve those numbers. A more reasonable conversion rate for most practices, according to him, would be in the 25-30% range.

“We still don’t have all the data we want to tell us how much better this is than standard surgery,” Dr. Patterson says. “Most of us using it believe it definitely is better, but it’s sometimes hard to justify the costs.

Additionally, practices that are considering buying a femtosecond laser system, which costs upwards of $500,000, may be concerned over how long the laser will remain the latest and greatest. Dr. Patterson points out the Summit and Sunrise systems were replaced by “systems that were significantly more effective, and eventually at less cost.”

“Most things I do buy and own, but with these big-ticket items, especially new technology big-ticket items — there’s an argument to be made for the roll-on/roll-off model,” says Dr. Patterson.


You can be cutting edge

For many small practices wanting access to femtosecond cataract surgery, roll-on/roll-off rental is an attractive alternative. Sightpath Medical launched the option last year, offering a mobile femtosecond laser suite for cataract surgery, complete with a manufacturer-certified laser engineer to come to your practice for a scheduled number of days each month. Sightpath offers the service on a per-procedure fee basis, requiring a 10-procedure minimum per visit.

Peter C. Kohler, MD, had extensive experience in both refractive and cataract surgery, so combining the two was immediately appealing to him. He wanted to have an option to offer those patients who wanted to be more independent of glasses. In the small town where he practices, Waterville, Me., sufficient demand simply did not exist to enable him to purchase his own femtosecond laser. “The population here is only about 15,000,” he explains.

… Without the risk

Because there is no laser payment to meet each month with the roll-on/roll-off model, practices are not under pressure to convert patients. Though Dr. Kohler is not interested in converting his patients, he does feel it is important to educate all of them about the femto-phaco option. “It’s not uncommon, though, especially among older folks, to have the attitude of, ‘I’ve worn my glasses all my life and I would feel funny without them.’ And that ends that discussion,” Dr. Kohler says.

Since initiating his femto-phaco practice, Dr. Kohler continues with the roll-on/roll-off model, even though he has merged with a group practice and now performs surgery out of his own ASC.

“But honestly, if I had it to do over again, I’d probably stick with the [roll-on/roll-off] model, even though my volume now has the potential to increase. The laser comes in the night before I do cases with an engineer who knows how to set it up, how to run it.”

If any problems occur during the case day, the engineers are trained in how to repair it. Additionally, “I don’t have to hire someone to learn that extra piece and for whom I’d have to find something else to do on the days I’m not doing FS cataract surgery,” Dr. Kohler explains.


It may be in their interest too

Practicing in a region he calls “pretty hard hit, economically,” wouldn’t seem to make one a good candidate for success with femto-phaco surgery, but Inder Paul Singh, MD, Racine, Wis., has managed to achieve it — without actually owning an FS laser.

Dr. Singh explains that in his southeastern Wisconsin area, “tucked between Milwaukee and Chicago,” the business of medical practice is hospital driven, with no ASCs. “All these hospitals compete with each other.” He realized this created an opportunity for him to present the acquisition of a femtosecond laser system as a way to benefit both himself and the hospital with which he was affiliated.

“I went to the CEO and said, ‘Look, there’s a new technology coming down the pike and I think it’s the wave of the future in cataract surgery,” he says. “I think if you get this technology, there’s a good chance that not only will I bring my patients from other hospitals to you, but you will also gain more volume.’”

After an eight-month conferral period, the hospital agreed and earmarked money for an FS laser. The fact that this was a smaller hospital made the process easier, Dr. Singh concedes. “I had direct access to the CEO, so it’s not like I had to go through numerous steps. But the hospital had to go through its financial models to decide.”

Making it pay

For the enterprise to succeed, femto-phaco had to be profitable for both parties, preferably as soon as possible. It was, far exceeding Dr. Singh’s expectations. Though the unemployment rate in the area is approximately 10%, he reports a conversion rate of about 50%. And that is with only internal advertising at his practice — the hospital, Dr. Singh says, wanted to wait a year and see his surgical outcomes before advertising femto-phaco to the community. His partner at his practice also uses the hospital laser, and a few other local practices have access as well.

Don’t write off purchasing

Of course, practices should investigate all options when considering the acquisition of a femtosecond laser system. Solo practitioner Scott LaBorwit, MD, of Towson, Md., purchased a femtosecond laser system two and a half years ago. He performs 30-40 cataract surgeries each week and estimates a 65% conversion rate to femto-phaco. His seven-year business plan for the femto-phaco system included the cost of the laser system, patient interfaces (“My business plan was about 15 cases per month to break even”), and the service contract ($3,000+ a month). “Add all that up over seven years, and you’re at about $1 million,” he says.

Dr. LaBorwit sees ownership as a wise “million-dollar investment.” The main advantage is access, he says. With business models that limit access, “how do you do the second eye?” he asks. “Or if the patient has to miss an appointment because his blood pressure is high, he may have to wait another month between the eyes.” If a practice has multiple surgeons booking the laser for each visit, scheduling can become difficult. “There’s an opportunity cost to not owning the laser.”

He feels surgeons are often so wary of purchasing a femtosecond laser system that they may not realize the opportunity, for example, if they find they have the interest in their patient base to support the purchase but are already committed to a lease. His advice is to write out a business plan for the laser. Use conservative estimates, but “play out the seven years and see what the numbers reveal, because it matters.”

Dr. LaBorwit also considers it an advantage to work with his own staff on surgery days. “I like having a technician with whom I am familiar, and who is familiar with me. It really helps with efficiency and that impacts your bottom line too.”

In addition, laser manufacturers may be amenable to helping lower-volume practices with the purchase. According to Daniel Wawrzyn Manager Public Affairs-Communications for Abbott Medical Optics, maker of the Catalys: “Abbott offers business solutions for all types of customers, including smaller accounts. The best approach for smaller practices is to get in touch with our representative and to work through their needs along those lines.”

“The hospital plans to contact the local newspaper because they want the paper to interview me on the technology — we are the only femto hospital in the southeast Wisconsin area.”

The hospital charges patients a facility fee when they choose femto-phaco, and Dr. Singh’s practice has a separate fee for the surgical side of the procedure.


Help them to understand astigmatism

The best way to educate his patients about the value of femto-phaco, Dr. Singh realized, was to help them comprehend astigmatism and its affect on the quality of vision.

“If patients don’t understand what astigmatism is, then for me to say that this procedure takes care of astigmatism doesn’t mean anything,” Dr. Singh explains. “Providing them this education helps them understand the value of the procedure. If we don’t take the time to do it, we see a significant reduction in the conversion rate.”

But Dr. Singh is also careful not to over promise. He tells patients he cannot guarantee that using the femto laser will mean a better visual result. “I say, ‘Look, I’m doing certain steps of the surgery more precisely than I could do them manually, but not always does that translate to a better outcome. However, it gives me the best chance of achieving the best possible outcome.’”

Dr. Singh says he is careful not to disparage standard cataract surgery as he educates patients, because he wants patients to feel confident if they decide on that route.

Reinforce the message

Patient education needs a multi-pronged approach, Dr. Singh finds. Giving patients the knowledge they need to make an informed decision entails reinforcement along the way.

When patients make appointments for cataract consults, the practice mails them literature about femto, as well as premium lenses. When they arrive for their appointment, the receptionist gives them another form about femto-assisted cataract surgery, and urges them to ask the technicians about the technology. When the techs bring the patients back for testing, they show them an educational video that explains the difference between standard and femto cataract surgery; the technicians also remind patients to ask the doctor about the technology, saying, “He’s very happy with this.” Then it’s his turn in the process.

Accentuate the positive

Confidence in the technology is key. Dr. Singh notes some surgeons object to emphasizing the femto option to patients, saying they don’t want to be salesmen. “I don’t want that either,” says Dr. Singh. “But I truly believe if we as providers believe in a technology, it is crucial that we express that to our patients.”

And when a femto-phaco surgery results in a good outcome — “Which is usually the case” — Dr. Singh lets the patient know that it is probably due to the laser. Patients then go out and tell their friends, and soon they come in asking about femto-phaco for their cataracts as well. Thus after barely a year’s time, the hospital’s investment in a femtosecond laser has paid off and provided it with a competitive advantage in the region.

Dr. Singh believes that while the roll-on/roll-off model is a good way to get started with femto-phaco, owning your own laser has valuable advantages.

“We did roll-on/roll-off with other refractive lasers, but we realized that having our own laser gave us more control,” Dr. Singh explains. “So many of our patients have astigmatism. Even if it’s only one-half or three-quarters of a diopter, there’s value in taking care of that. When we perform refractive surgery, our goal is to get rid of every bit of refractive error possible.” OM

View the original article on Ophthalmology Management here.